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Venous Thromboembolism Prophylaxis in Orthopedic Surgery

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Preventing Venous Thromboembolic Events in Major Orthopedic Surgery

Major orthopedic surgical procedures—total hip replacement (THR), total knee replacement (TKR), and hip fracture surgery—carry a high risk of venous thromboembolism. Strategies to prevent VTE include pharmacological and mechanical modalities, used alone or in combination. This systematic review included these pharmacological classes of thromboprophylaxis: oral antiplatelet agents, injectable low-molecular-weight heparins, injectable unfractionated heparin, injectable or oral factor Xa inhibitors, injectable or oral direct thrombin inhibitors, and oral vitamin K antagonists.

After this report was updated, the U.S. Food and Drug Administration (FDA) approved an oral direct factor Xa inhibitor, rivaroxaban, for the prevention of deep vein thrombosis, which may lead to pulmonary embolism, in patients undergoing knee- or hip-replacement surgery. Four phase III trials have been completed at this time. Since this drug did not carry an FDA-approved indication until recently, rivaroxaban did not meet the inclusion criteria and was not included in this review. However, these trials are relevant since they provide new information for an additional between-class comparison (oral direct factor Xa inhibitor vs. injectable low-molecular-weight heparin). The main findings of the four trials and the outcomes reported in these trials will be described separately.

Classes of mechanical interventions included were graduated compression, intermittent pneumatic compression, or venous foot pump. Finally, results from comparisons of combinations of these interventions are reported.